Provider Demographics
NPI:1609374826
Name:LACOSTA, CARLENNE (BCBA)
Entity Type:Individual
Prefix:
First Name:CARLENNE
Middle Name:
Last Name:LACOSTA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26720 YNEZ CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4659
Mailing Address - Country:US
Mailing Address - Phone:951-813-4034
Mailing Address - Fax:951-813-4035
Practice Address - Street 1:3355 MISSION AVE STE 221
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1328
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:951-813-4035
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-21-12673106E00000X
CARBT-16-17023106S00000X
CA1-22-60843103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician